Nova Scotia Coordinated Access Housing Application Section 1 - Applicant

Primary Details Salutation Mr. Mrs. Ms. Miss Last Name First Name Middle Name Maiden Name Marital Status Single Divorced Common Law Married Widowed Other Date of Birth (MM/DD/YYYY) Sex Male Female Social Insurance Number (SIN) Student Yes No Name of School Status in Canada Canadian Citizen Landed Immigrant Other Specify if Other

Priority Access (This pertains to all household members listed on the application) I/We are victim(s) of family abuse. If you checked any of the checkboxes, I/We are required to live in a location close to life sustaining health services please specify details: I/We currently occupy inadequate housing which poses an immediate health and/or safety risk

Current Address Street No. and Name Apt. No. City Province Postal Code Country

Mailing Address (if different than current address) Street No. and Name Apt. No. City Province Postal Code Country

Telephone Numbers Home E-Mail Address Work Can we safely contact you at your mailing address and home phone number? Yes No Cellular If No, where can we contact you?

Present Accommodation Home Information Own Rent Temporary Homeless Shelter Boarder Monthly Housing Expenses: Please include monthly mortgage payment or monthly rent and average monthly electricity, water, heating fuel and taxes, as applicable. $

Current Landlord Information (Please leave this section blank if you reside in you own home or are homeless)

Landlord Name Telephone Number Length of Tenancy (Months) Have you received an eviction notice? Yes No Eviction Date Eviction Reason

Persons to contact in your absence Name Relationship Telephone Number Nova Scotia Coordinated Access Housing Application Section 2 - Co-Applicants / Other Members

Leaseholder Yes No Relationship to Applicant Salutation Mr. Mrs. Ms. Miss Last Name First Name Middle Name Marital Status Single Divorced Common Law Married Widowed Other Date of Birth (MM/DD/YYYY) Sex Male Female Social Insurance Number (SIN) Student Yes No Name of School Status in Canada Canadian Citizen Landed Immigrant Other Specify if Other

Leaseholder Yes No Relationship to Applicant Salutation Mr. Mrs. Ms. Miss Last Name First Name Middle Name Marital Status Single Divorced Common Law Married Widowed Other Date of Birth (MM/DD/YYYY) Sex Male Female Social Insurance Number (SIN) Student Yes No Name of School Status in Canada Canadian Citizen Landed Immigrant Other Specify if Other

Leaseholder Yes No Relationship to Applicant Salutation Mr. Mrs. Ms. Miss Last Name First Name Middle Name Marital Status Single Divorced Common Law Married Widowed Other Date of Birth (MM/DD/YYYY) Sex Male Female Social Insurance Number (SIN) Student Yes No Name of School Status in Canada Canadian Citizen Landed Immigrant Other Specify if Other

Leaseholder Yes No Relationship to Applicant Salutation Mr. Mrs. Ms. Miss Last Name First Name Middle Name Marital Status Single Divorced Common Law Married Widowed Other Date of Birth (MM/DD/YYYY) Sex Male Female Social Insurance Number (SIN) Student Yes No Name of School Status in Canada Canadian Citizen Landed Immigrant Other Specify if Other Nova Scotia Coordinated Access Housing Application Section 3 - Previous Tenancy Please specify previous 3 tenancies or previous tenancies up to 3 years for Applicant and Co-Applicant(s), whichever is longer:

Have you ever been a tenant in: Public Housing Yes No Rent Supplement Yes No Non-Profit Yes No Other Yes No Cooperatives Yes No If Other, specify

Applicant/Co-Applicant Occupancy From (MM/YY) Address Line 1 Occupancy To (MM/YY) Address Line 2 Landlord Name

City Landlord Phone No. Province, Postal Code Country Applicant/Co-Applicant Occupancy From (MM/YY)

Address Line 1 Occupancy To (MM/YY) Address Line 2 Landlord Name City Landlord Phone No. Province, Postal Code Country

Applicant/Co-Applicant Occupancy From (MM/YY) Address Line 1 Occupancy To (MM/YY) Address Line 2 Landlord Name City Landlord Phone No. Province, Postal Code Country

Applicant/Co-Applicant Occupancy From (MM/YY) Address Line 1 Occupancy To (MM/YY) Address Line 2 Landlord Name City Landlord Phone No. Province, Postal Code Country

Applicant/Co-Applicant Occupancy From (MM/YY) Address Line 1 Occupancy To (MM/YY) Address Line 2 Landlord Name

City Landlord Phone No. Province, Postal Code Country Nova Scotia Coordinated Access Housing Application

Section 4 - Income Statement of all MONTHLY income BEFORE deductions received by all persons/family members to live in the accommodation

Applicant Last Name ----> Applicant First Name ----> Income Categories $ Amount $ Amount $ Amount $ Amount Alimony/Child Support Capital Gains Canada Pension Plan Disability Canada Pension Plan Other Dividends Employment Insurance Employment Income Foster Child Payments Gratuities Immigrant Sponsorship Human Resource Development Canada Interest Old Age Security/Guar. Income Supp./Spouse Allow. Other Country Social Security Other Income Other Pension Rental Income RRSP/RIF Social Assistance Student Loan Workers Compensation Veteran Pensions & Allowance Total Income for member: $

Total Income for the household per month: $ Nova Scotia Coordinated Access Housing Application

Section 5 - Housing Preferences Note: Select unit size based on your family size. These preferences will determine the properties that are suitable for your selection based on your requirements. Housing accommodations may not be available to meet all of your requirements.

Unit Size : Bachelor 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Bedroom 6 Bedroom

Resident Type: Non Elderly (57 yrs I/We want to live in a community for: Family Senior old or under)

Accessibility: Is anyone in your household disabled? Yes No I/We require one or more of the following: Wheel Chair Accessibility Ground Floor due to inability to climb stairs

Paraplegic Unit / Modified Unit Hearing Impaired Unit

Visually Impaired Unit

Other If Other Specify:

Supportive Services Required: I/We are required to live in a location where essential support services are available:

Specify: Do you currently have home support services? Yes No

Other Details: Is anyone in the household a smoker? Yes No

Do you own a house? Yes No Do all household members reside in present accommodation? Yes No

If No provide information in notes box

Do you currently have a pet? (This is subject to Housing Authority Approval) Yes No

Do you require parking? Yes No

Nova Scotia Coordinated Access Housing Application

Section 5 – Senior Housing Preferences Public Housing Program South End Halifax Dartmouth South End Seniors □ Acadia Place 8 Mount Hope Ave □ (Joseph Howe Manor 5515 Victoria Rd, H.P. MacKeen Manor 1186 Alderney Manor 1 Alderney Dr □ Queen St) **Eastwood Manor 55 Crichton Ave □ Central Halifax Edgemere Manor 79 Crichton Ave □ Gordon B. Isnor Manor 5565 Cornwallis St □ Crathorne Place 14 & 16 Jamieson St □ Sunrise Manor 2406 Gottingen St □ Nantucket Place 45 Ochterloney St □

Halifax West Cole Harbour/Eastern Passage Sir John Thompson Manor 7001 Leppert St □ *Forest Hills 16, 18,*20, 22 Circassion Dr □ Westmoor Lodge 6841 Cook Ave □ Island View Apartments 36 Cow Bay Rd □ D A MacDonald Manor 1935 Caldwell Rd □ Fairview Spruce Grove Apartments 27 James Roy Dr □ **Cornwallis Morreau Lodge 103 Main Ave □ Sarah Jane Clayton Manor 1 Lower Governor □ MacDonald Laurier Place 3 Ford St □ Bedford/Sackville Woodlyn Manor 2 Woodlyn Dr □ Halifax North Bedford Manor 51 Bridge St □ **Dr Samuel Prince Manor 3792 Novalea Dr □ *McDougall Manor 20 McDougall Ave □ Richmond Manor 5594 Northridge Dr □ Glendale Manor 1 Smokey Dr □ Acadia Square Lodge **Devonshire Ave/Kenny Dr □ Sackville Manor 51 Old Beaverbank Rd □

Spryfield Area County Area Captain William Spry Lodge 6 Arnold Dr □ Waverley Manor 12 Faucheau Ln □ Cowie Hill Lodge 166 Cowie Hill Rd □ Enfield Manor 41 Parker Place Crescent □ Margaret Latter Manor 144 Hebridean Dr □ Valley View Villa 28 Elm Dr □

St Margaret’s Bay Area Musquodoboit Harbour Timberlea Manor 1746 Bay Rd □ Forest Glen Apartments 19 East Petpeswick Rd □ Eleanor Hubley Villa 9 Eleanor Ln □ Sheet Harbour Hubbards Manor 19 Fox Point Front Rd □ Elmhurst Apartments 14 Elmhurst Dr □

Section 5 – Senior Housing Preferences Affordable Housing Program

Woodside 8b/8 Mount Hope Ave Lower Sackville Minimum Income: $23,000 per year

*Fort Clarence Place Minimum Income: $22,000 per year □ *Millwood Manor 114 Millwood Dr □ *Sackville Manor II 51 Old Beaverbank Rd □

Spryfield Minimum Income $22,000 per year 110 Lyons Ave

*Ida Mae Marriott 1 Bedroom $640,2 Bedrooms $740/month □

*Non-Smoking Building **Building with designated non-smoking floors

Nova Scotia Coordinated Access Housing Application

METROPOLITAN REGIONAL HOUSING AUTHORITY

Tel: 420-6017 Application Fax: 420-2815

Prior to assessing your application; staff complete a Nova Scotia Power Confirmation and arrears check.

1). Power Confirmation: Nova Scotia Power is contacted to confirm that power can be installed in the leaseholder(s) name. If power arrears exist, applicant is to contact Nova Scotia Power prior to being housed to resolve arrears.

2). Arrears with a housing authority or any government funded housing agency: If arrears exist you will be notified of the amount and your application will be cancelled. Once the arrears have been paid, you may reapply.

Once an application has cleared the above checks, it is forwarded to the Applications Department. A staff member will contact you to complete an assessment within two (2) weeks.

Please be advised all income confirmations will be required. The table below lists som e e xample s o f the income verification that may apply to you.

Please call Service Canada to request an Income Confirmation Letter for the following: Old Age Security, Canada pension, Guaranteed Income Supplement Phone: English-1-800-277-9914, French-1-800-277-9915, TTY-1-800-255-4786 (If couples, one letter each)

Stubs / Letters from Superannuation to confirm your gross monthly income

Stubs / Letter from D.V.A. /W.V.A/ Canadian Forces Pension to confirm your gross monthly income.

Stubs / Letters from Retirement Pension to confirm your gross monthly income.

Confirmation of all investments income, from all sources. i.e., Registered Retirement Investment Funds, savings, G.I.C.s, Debentures, etc.

Self Employed / Business Income – A certified copy of this year’s Income Tax Assessment, both personal and business, including financial statements filed with the tax returns.

Last 4 current pay stubs, or a letter from the employer stating the hours worked per week and the rate of pay. Please ensure the business name and contact number is on the letter.

Employment Insurance (EI) stubs, covering the proceeding 4 week period or a Record of Employment (ROE) issued by Employer.

Confirmation of any insurance received monthly or yearly.

Current stub or budget sheet, from Income Assistance/Family Benefits

Confirmation of all alimony/support received monthly.

Verification from incomes not mentioned above Additional Information: Official copy of current custody agreement

If you have any questions about your eligibility for housing or the assessment process, please call the Application Department at 420-6017

Nova Scotia Coordinated Access Housing Application

Nova Scotia Coordinated Access Housing Application

Declaration and Consent: Please read and sign this statement:

I/We declare that the information provided in the application form is correct and complete.

I/We understand that falsification of any or all information provided by me/us may be cause for the cancellation of the application.

I/We understand that it is my responsibility to advise the Housing Authority of any changes to the information given in this application (i.e. change of address, telephone number, etc.) and to provide any supporting materials required for my/our application.

I/We authorize the Housing Authority or its representatives to make inquiries that are necessary to verify the information submitted in this application.

I/We authorize the Housing Authority to receive and exchange with my/our current and previous landlord(s), N.S. Power and other information about me/us to be used in the decision making process to provide me/us with rental accommodation.

Applicant’s Signature ______

Co-Applicant’s Signature ______

Application Date ______

METROPOLITAN REGIONAL HOUSING AUTHORITY 3770 Kempt Rd, Suite 3 HALIFAX, NOVA SCOTIA B3K 4X8

PHONE: 420-6017 FAX: 420-2815